Provider Demographics
NPI:1760562474
Name:FANG, HSIEN TA (MD)
Entity Type:Individual
Prefix:
First Name:HSIEN TA
Middle Name:
Last Name:FANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 22ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1563
Mailing Address - Country:US
Mailing Address - Phone:630-573-5000
Mailing Address - Fax:
Practice Address - Street 1:120 SPALDING DR
Practice Address - Street 2:SUITE 410
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6508
Practice Address - Country:US
Practice Address - Phone:630-369-0780
Practice Address - Fax:630-369-0886
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103303207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616108OtherBLUE CROSS BLUE SHIELD
IL036103303Medicaid
ILG41834Medicare UPIN
ILL82137Medicare PIN